Your Insurance: UnitedHealthcare
In June of 2021, UnitedHealthcare (UHC) settled a class-action lawsuit alleging that it failed to cover lipedema. They issued a coverage policy for liposuction for lipedema that is effective on October 1, 2021.
Once an insurer has a coverage policy, you cannot expect to pay upfront and submit a claim later. You need to request pre-certification, and getting a “coverage” letter doesn’t guarantee you will be paid fairly. We do not recommend paying an out-of-network surgeon and submitting a claim later because insurers may only reimburse a few thousand dollars or less for your surgery. It’s far better to work with a surgeon who will lower their rates and enter into an agreement with an insurer in advance, so they are treated like an in-network surgeon.
The new UHC policy does not address finding a qualified surgeon. If you plan on using an out-of-network surgeon, it will take our knowledge, experience, and connections to get covered. Depending on your state, insurance plan, and employer, your success rate can vary widely without our help. Sometimes a surgeon or patient gets lucky, but we can get patients approved for an out-of-network surgeon most of the time and, if not, assist with finding a qualified in-network surgeon.
The coverage policy prevents UHC from arguing that surgery is experimental or unproven. However, we expect that instead of issuing blanket denials, their clinical team will scrutinize individual requests and deny them based on the diagnosis, conservative measures, and functional impairment. We have been helping women with UHC get covered for years and have the connections, data, and experience that quickly resolves these issues. We recommend that you work with us from the start to minimize the chances of having to appeal a denial which is more costly and time-consuming.
The UHC policy doesn’t cover skin excisions as other plans do, but we have been able to get UHC to cover excisions which can include a panniculectomy rather than liposuction on the abdomen.
The UHC coverage policy is also more restrictive than many of other insurer policies in regards to conservative treatment. UHC requires six months instead of three months of conservative therapy. UHC also seems to want more documentation for women who have a BMI over 35. If you have a BMI over 35, we do not believe you need to undergo bariatric surgery or take diet drugs to get covered. We are happy to work with you to document your weight loss efforts, and we have a dietician you can consult with who understands the difficulty of weight loss for lipedema patients.
The UHC policy also requires a referral from a Primary Care Provider (PCP) or a vascular specialist. We have several non-surgeon lipedema experts who can help you document lipedema. Some have a primary care specialty, and some can assist you in gaining support from your PCP. We also have several strategies and suggestions to educate your PCP on lipedema. We generally do not recommend seeing a vascular specialist because they tend to recommend vascular procedures before recommending lipedema surgery. If vascular surgery is recommended, we suggest you speak with a lipedema surgeon as lipedema surgery can often improve vascular flow restricted by lipedema tissue pressing on veins. If you do use a vascular specialist, then it’s very important that they properly document the lipedema by following our Coverlipedema.com process.
At Coverlipedema.com we always recommend that our members have a detailed independent functional capacity evaluation or FCE to have a strong coverage request. Several years ago, we found a company that performs FCEs for worker’s compensation and disability cases and helped them adapt their assessment to lipedema. We also use FCEs extensively in the out-of-network request and contract negotiation process.
Regarding out-of-network surgeons in states like California and Ohio, UHC will likely refuse to pay for surgery with them because there are in-network surgeons. So, we do not recommend traveling to these states for surgery. In other states, we are usually able to help Coverlipedema.com members work with the surgeon of their choice. For the best chance of being covered for an out-of-network surgeon, we don’t recommend traveling too far from your home state. Plans have been clear that, if you will travel for an out-of-network surgeon, you can travel for an in-network surgeon. However, your type of plan and the state where you live are important factors.
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